Riding on the train last week, I talked with a fellow passenger about "fakes." That's because my traveling companion is a business consultant who specializes in uncovering fraud, especially related to counterfeit money. Our conversation turned to the 2002 movie, Catch Me if You Can, with Leonardo DiCaprio playing the role of Frank Abagnale Jr., who for years posed as a pilot, a prosecutor and a Georgia physician, scamming millions of dollars along the way, before he became a law-abiding citizen.
"The fraud," he said, "is relentless. It keeps coming."
I was thinking about that conversation after I read this news story about "fake" doctor who treated more than 1,000 people in 2 states, collected $1.2 million for the "care" he provided, and then tried to sell their health information.
The guy who didn't have a license to practice medicine is Matthew Paul Brown, 30, formerly of Atlanta, GA and Nashville, TN, who eventually pleaded guilty in federal court in Atlanta to healthcare fraud and wrongful disclosure of individually identifiable health information.
As Commins' reported, prosecutors said Brown worked with licensed physicians in both states from November 2009 to April 2011 and used their provider numbers to collect about $1.2 million in false claims with Medicare andMedicaid and private insurance companies. He would administer the care in the physicians' offices and at health fairs, with physicians agreeing to pay Brown between 50% and 85% of their take.
Those docs who agreed to pay Brown were really taken for a ride, which ended up being costly for everyone involved, physicians and patients included.
If the doctors who worked closely with Brown paid more attention, however, they could have halted the scheme quickly, and that's a lesson in itself.
"Brown tricked the physicians into believing that he was also a doctor," says Patrick Crosby, spokesman for the U.S. Attorney. "These techniques would not have been successful if the physicians had verified his credentials."
Brown purported to provide allergy testing and immunotherapy for patients at more than 20 health fairs and various work sites, according to the grand jury indictment I reviewed. Although the U.S. Attorney's Office says they are not aware of anyone seriously injured by Brown's actions, "because of the number of patients, it is possible that some victims have suffered injuries we are not aware of," says Crosby.
Brown convinced at least six physicians to pay him loads of money for his work. Not only didn't they check who he was, they left him alone for much of the time while he was reviewing patients' conditions at job fairs or offices. The physicians also agreed to Brown's proposal to allow him to perform allergy and immunotherapy testing in their offices, bill the services to healthcare benefits programs under the host physicians' provider numbers, and pay Brown half of the ill-gained fees from the benefit programs, prosecutors say.
Maybe the real physicians and their fake colleague were in a hurried environment. Maybe the real docs were thrown off by the white coat Brown wore, embroidered with the words "Dr. Matthew Brown," court records show.
And maybe because Brown said he was an "expert" on allergies, the licensed physicians simply took his word for it, especially since they weren't in the field he had claimed as a specialty. Finally, the young "doctor" never asked for any supervision or assistance when he was with patients, nor, apparently, was any offered.
One other tidbit in the indictment: Although he was seen wearing the "Dr. Brown" pin, he told one fellow physician that he was a nurse practitioner.
Too bad the doctors didn't get a chance to talk about their new colleague sooner at the water cooler, and trade some notes. It might have saved everyone a lot of grief.
Indeed, while Brown was with patients, none of the licensed doctors had seen him work, the indictment states. Brown gave "physicians the impression that he was a qualified allergist who needed no supervision," the indictment states.
In a cadence that read like Dr. Suess's The Cat In The Hat, the indictment notes: "The physicians did not supervise Brown when performing allergy testing in their offices and they did not supervise Brown when he interpreted results of the allergy tests." After Brown interpreted the allergy tests, he sometimes prescribed immunotherapy to the patients. As he carried out his supposed specialty, he purchased needles and allergy medicine from a pharmacy and created a spreadsheet with information about patients he treated.
Eventually, and predictably, Brown's quest for money did him in. He sent the spreadsheet to an undercover FBI agent who Brown believed was "an investor considering a large investment in Brown's business," authorities said.
So what was Brown's take? "The exact amount has not yet been made public," says Crosby. What is known, is that "Brown caused over $2.9 million to be billed to healthcare benefit programs, and over $1.2 million to be paid out by them."
Brian D. Lamkin, the special agent in charge of the FBI's Atlanta field office, said in a statement that Brown's conduct "not only displayed a total disregard for the patients that he was improperly and illegally treating, but also for those individuals who could have legitimately benefitted from the federal Medicaid/Medicare funds."
Brown' was finally apprehended in an undercover sting that resulted from his own quest for even more money, authorities say. He pleaded guilty to 17 counts of healthcare fraud, each with a maximum sentence of 10 years and a fine of $250,000. And he also pleaded guilty to wrongful disclosure of individually identifiable health information, in violation of the Health Insurance Portability and Accountability Act (HIPAA).
Sentencing is scheduled Nov. 22.
Real physicians, especially those in the allergy field, are upset by the scam. "I find it particularly disturbing that any physician would allow someone with questionable medical credentials to provide care, much less specialist level care, for their patients," John Overholt, MD, of the Allergy & Asthma Associates of Middle Tennessee wrote on his web site.
"This is a clear case of greed outweighing the best interest of the patients."
Mary Anne Graf, vice president of Women's and Children's Services at Bon Secours Richmond Health System asked her audience at HealthLeaders Media Rounds on Women's Health Strategy in Richmond, VA last week to look closely at her Power Point slide.
The slide was headlined:
"Examples of Obstetrics: Outstanding EMR (electronic medical records) Integration Experiences."
The rest of the slide was blank.
That empty space represented what Graf believed were those hospital obstetrics programs that initiated EMR programs, but were happy with their experience. Zero. "That's the list," Graf said, noting that she had spoken to many hospital executives around the country about the lack of EMR for obstetrics programs.
"It's a problem," Graf added. A hospital may invest millions into EMR, and the bulk of the business goes to medical-surgical units, she added, not obstetrics. The lack of electronic medical records could have dire consequences for patients. "You can lose a woman or a baby very quickly in the operating room, [or] in labor-delivery" without the proper medical dosages. "It's a very difficult issue that we're coming to grips with. Everywhere there has been an issue," Graf explained.
Indeed, the question of EMR integration is an issue that healthcare facilities must confront as they step up implementation of programs for women's service lines, which has significant potential for growth, Graf says.
Whether launching perinatal care programs or trying to harness electronic medical records, health systems must tap into innovative programs to realize the potential for growth in women's health programs, Graf and other panelists told the HealthLeaders Rounds audience.
Other speakers were Michael Spine, senior vice-president, business development, for Bon Secours, and two officials from Geisinger Health System, Danville, PA: Harry O. Mateer Jr., MD, FACOG, director of obstetrics and gynecology, and Ruth Nolan, PhD(c), RNC, vice president of operations, women's health service line.
"Gender-specific care for women is just now starting to be explored," Graf said. "It has significant potential in an ACO environment."
Nationally, maternal fetal medicine (MFM) procedures expect a 9% volume increase; including a 16% increase in telemedicine, and 20% increase in high-level ultrasounds. There also are anticipated increases in gynecological subspecialties, such as pelvic floor disease, 27%; ovarian cancer, 10%, and uterine cancer, 11%, according to Graf.
Those figures buttress reports that 55% of health systems expect women's service lines to become more significant, he added, with "continuum of care in obstetrics" becoming more important.
Bon Secours is working to improve its perinatal program in a model similar to that initiated by the Geisinger Health System. Graf noted that Bon Secours is considering a co-management program to engage private and employed providers in an accountable care organization type structure, in an effort to increase revenue and generate improved patient outcomes. "There [are] margins out there, but in areas we have yet explored," Graf said, referring to profitability potential within the service line.
Geisinger initiated Perinatal ProvenCare, a program to improve efficiency and outcomes in obstetrics care, says Mateer.
Before launching the program, hospital officials weren't satisfied with performance of their perinatal program. "There was a lot of variability in the system," Mateer said. "We decided we had to redesign, from the ground up, all aspects of provider workflow." The Geisinger system handles about 5,000 pregnancies and 4,500 annually, with 75 clinicians at 24 clinic sites.
Under the Perinatal ProvenCare model, at least 100 "evidence-based elements of care are incorporated, measured and tracked for compliance," according to Mateer. That includes EMR. For instance, the hospital system created a record system known as eForms that enable nurses and providers to complete documents that reflect care coordination, for instance, Mateer said.
"It's about tailoring care specific to the patient. That also helps us avoid waste. We don't just throw this blanket out there and try to do the same thing for everyone," Nolan said.
The hospital system has increased patient safety, reduced documentation redundancy, streamlined patient education and reduced costs, Mateer said. Implementing improved education programs, one of the Geisinger hospitals, the Geisinger Wyoming Medical Center, Wilkes-Barre, PA, reduced caesarian section deliveries by 32% from 2008 to 2010.
Generally, to improve care, health systems need to initiate change, but it's not easy, Nolan said. "It's about doing things very differently than what we have done in the past," she said. "Another unfortunate truth in healthcare is the assimilation of best practices is painfully slow."
"All of us are facing the same challenges, clinically integrated networks or accountable care organizations integrated delivery models, " said Spine, the senior vice-president for business development at Bon Secours Richmond Health System. "The reality is the same: most of the government, state, and federal as well as (payers) want high quality at the lowest possible cost."
Over the last several years, there have been concerns that the bone-strengthening drugs used by millions of post-menopausal women could have reverse impacts for some who may take the medication for years. The Food and Drug Administration is considering whether there should be more stringent warnings after reports of inexplicable fractures suffered by users who took the drugs for five years or more.
Jennifer P. Schneider, MD, a 69-year-old physician from Tucson, AZ, says the FDA isn't tough on controlling the drugs, generically known as bisphosphonates. Schneider speaks from experience. A decade ago, as she stood in a New York subway car, Schneider collapsed under a fractured femur. She had been taking Fosamax for seven years. Other bisphosphonates include Actonel and Bonivan.
This month, Schneider attended a hearing of two FDA advisory committees, and testified that she conducted a study of 111 patients and found problems among those who had taken the medication for 5 years or more. Their bones "were as fragile as when China dishes fall," she says. Like her, those patients had taken the drugs for osteopenia, a pre-osteoporosis condition. Now she is leading efforts to improve warnings for people who take bisphosphonates.
The FDA issued advisories last Friday about the medication, but has yet to rule on drug labeling language. Schneider believes the agency should impose tougher restrictions, such as so called "black box" warnings that she says would reduce the number of people taking the medication for several years. The agency states that only about 1% of patients take the drugs for longer than five years.
Black box warnings refer to serious complications related to a drug or life-threatening impacts.
The advisory panels that heard Schneider and others testify agreed that there should be enhanced "cautionary language" on the product, but they didn't say what that language should be, or whether there should be a limit in the length of time the drug is used, according to The New York Times, which estimates that 11 % of women 55 and older take the drugs to prevent bone fractures.
Over the years, the drugs have been shown to slow bone loss, increase bone density and cut fracture rates in women with osteoporosis.
But there have been reports linking the drugs to osteonecrosis of the jaw and the femur fractures. The fractures sometimes occurred in both femurs and recovery period was lengthy, Schneider says. The FDA last year issued a safety announcement requiring warnings to physicians and patients about the potential complications of the drugs. Schneider insists those warnings aren't effective.
"Most doctors won't read a 40-page insert (safety announcement). You need to catch a doctors' attention," Schneider says. "The advisory was a good first step, but I'm hoping for the black box warning." Schneider leads a support group of women, and some men, who suffered similar bone-fracture experiences to hers. "We are constantly educating doctors because it's amazing how many doctors don't see the warnings," and lack of awareness of potential complications, she says.
Schneider, an internist who has specialized in addiction, has spent a career working on pain management issues. Now, as a part-time physician, she has doggedly sought changes in government policy related to the bone issue.
"I think they are totally waffling," Schneider says, referring to the FDA. Interestingly, FDA's staff has suggested that benefits of the drug have not been proven longer than three to five years. The FDA's advisory committees weren't quite so definitive. While the agency often listens to its advisory committees, it doesn't have to, Schneider notes.
Schneider has written extensively on the subject, interviewing other patients who related horror stories like hers. In 2009, she wrote a report in Geriatrics, referring to patients who developed "spontaneous" stress fractures after they had taken the drug for several years.
Schneider pointed to a recent Canadian study published in the Journal of the American Medical Association stating that women who had been on biosphonates for more than five years had shown a risk of the atypical fractures.
The FDA acknowledges the bone-strengthening drugs must be reviewed. The committees noted that hearings were conducted "in light of recent safety events that appear to be potentially associated with long-term use of bisphosphonates." Drug makers say there shouldn't be a limit on the years the drugs are used.
Schneider is a plaintiff in a lawsuit against Merck, the maker of Fosamax. She insists that the suit is not motivating her efforts to change government policy. An estimated 1,000 lawsuits have been filed against Merck.
"These cases take so many years," Schneider says of her lawsuit. "They are being litigated one at a time; it isn't a class action thing. ""There are hundreds of cases and most of them may wind up in a courtroom run by the same judge. The chances of (mine) being litigated and resolved are very remote. I'll be dead before that happens," she aid.
The FDA may consider issuing a new label for the drugs in November. Schneider was disappointed in the advisory committee meetings, but she's ready to speak her mind. "Anytime there is an opportunity to talk to them, and keeping the issue fresh, that is still progress," she said.
HealthLeaders media Live from Barrow Neurological Institute at the St. Joseph’s Hospital and Medical Center, Phoenix
Simply put, there hasn’t been much progress in healthcare’s ability to extend life expectancy for those with brain tumors over the past three decades.
So says Phil Pomeroy, vice president of neurosciences at Barrow Neurological Institute, located at the St. Joseph’s Hospital and Medical Center in Phoenix. Pomeroy is responsible for business development and strategic planning for Barrow.
Healthcare is “not exactly moving closer to a cure,” Pomeroy says. “Ultimately, brain tumors are devastating.” But Pomeroy says Barrow is working to make an “impact and a difference.”
Against that backdrop, the BNI has taken steps toward improving such brain tumor research programs especially through varied clinical approaches that can lead hospital officials to improve brain tumor care, Pomeroy said at a HealthLeaders Media Rounds event, “Neurological Service Line Growth: Telestroke & Brain Tumor Innovations,” held in May at Barrow.
Building a brain tumor program is defined by lengthy pathways and initiating a strict clinical plan, says Pomeroy. The hospital is exploring new treatment options including molecular targeting, stem cell research, and neuro-oncology planning.
“We are finding folks who are looking for potential solutions through clinical trials and basic research, and with some degree of hope with experimental therapies,” Pomeroy says. Patients are attracted to new protocols and “will travel long distances” if necessary, he says.
The Barrow Brain Tumor Research Center concept includes neurosurgical intervention, neuro-oncology consultation, and radiation-based therapy. Barrow developed its program with the backdrop of a brain tumor cancer center “vacuum” in the Southwest and brain tumor research shifting from the national to the local level. The hospital includes 64 licensed and staffed neuro-intensive care beds, 80 licensed and staffed neuro acute-care beds, and 11 neuro operating rooms.
Key areas of development include “homegrown therapeutic solutions,” a complete clinical trials program, and providing experimental therapy options for every patient, according to Pomeroy.
“It is really built on a foundation of research,” Pomeroy says.
A “successful clinical program requires clinical focus, market differentiation, educated resources, and visionary leadership,” he says, as well as a “well-conceived plan.”
Pomeroy says the brain tumor research program has yielded benefits in terms of clinical research as well as patient outcomes.
Pomeroy says the program has resulted in at least a 50% increase in clinical research projects, including a doubling of peer-review populations, as well as additional professional education seminars and patient and caregiver conferences.
Michele M. Grigaitis, DNP, FNP-BC, CNRN, a nurse practitioner in the division of adult neuroscience at Barrow, says the hospital has used advanced practice nursing that has resulted in improved efficiencies, such as contributing to reduced length of stay for patients. The nursing staff works cohesively with the hospital’s 20 neurosurgeons for standardization of care.
For the nurses, evaluating length of stay is important, Grigaitis says. They can help enable a patient to be discharged directly from the intensive care unit “instead of taking them to the floor where they will be spending extra days.”
The development of clinical programs is significant because of the lack of progress in the brain tumor research field, according to Pomeroy.
An estimated 63,000 Americans were diagnosed with brain tumors in 2010, and 612,000 patients currently live with a primary brain tumor.
“Progress to date has been limited, even with cost being no object,” Pomeroy says. The late Sen. Edward M. Kennedy survived 14 months after diagnosis, and journalist Robert Novak survived 13 months.
“Our survival rates in 1980, compared to 2010—we have gained only four months, so we’re not exactly moving closer to a cure,” Pomeroy says.
Barrow is working to make inroads in evaluation of brain tumors, he says. “Our concept is built on a foundation of research, lab work, and clinical trials, and [is] tied into a high volume of patients that feed the clinical trials,” Pomeroy adds. He describes Barrow’s approach as “home grown; it’s really taking innovative approaches to therapeutic solutions that will open some new doors, and we already have.”
“We’re not in the top ranking among [hospitals conducting] clinical trials, but when you look at enrollment we are at the top of the list,” he says. “We are offering a high volume of cases, and the more you do, the
better you are; like in many disciplines, it relates to better outcomes and
therapy approaches.”
Researching a prospective “tumor vaccine is something we are pursuing,” he says. In developing programs, whether telestroke or brain tumor research, “having clinical focus is absolutely critical,” Pomeroy says.
Funding sources for the Barrow programs include the National Institutes of Health, focusing on areas ranging from basic science research, advanced diagnostics, or therapeutic innovations. “I think increasing our clinical volume will be a substantial indicator of our success,” Pomeroy says.
This article appears in the September 2011 issue of HealthLeaders magazine.
On the train to New York on September 12, 2001, the day after the devastating attacks, I could see the smoke still rising from the debris that was once the World Trade Center's Twin Towers. Closer to the site, as I walked the streets littered with burned cars, the air was heavy with a metallic smell that still haunts me today.
Nearly 3,000 people were killed that day in the suicide attacks in New York, Washington D.C., and Pennsylvania, but the ruinous assault continues, in a sense. That smoke was part of the problem, and questions remain from the disaster's odious dust. Physicians and hospitals are playing key roles in determining the medical extent of the 9/11 aftermath in New York. Ten years after the attacks, continual and chronic medical conditions plague the people who worked at Ground Zero.
I was a journalist then, too, sent to cover the horrific event. As another reporter and I walked the cluster of blocks near the fallen WTC, we knew that the lingering smoke and acrid smells could only foretell hazards ahead for public health. After holding handkerchiefs to our mouths, we realized these were inadequate protection from the fumes and choking swirl of soot. We joined many others in seeking out masks. Pharmacies were selling out fast. Finally, we found a couple that would stanch the odor and, we hoped, the suspicious particles.
The following week in New York was a blur of sadness, dust, and despair. The clouds of smoke lingered, burning throats and stinging the eyes of thousands of volunteers who worked on search and rescue. We talked to people who waited in long lines scouring lists of wounded and maimed, hoping to see a husband, daughter, a friend, holding pictures of missing people and telling their stories. They, too, were exposed to the noxious air quality—but that was the least of their concerns.
First responders—people who came from all over the country to help in the cleanup and recovery efforts—are still struggling with lung conditions. Thousands have shown signs of debilitating illnesses from breathing dust at the site. Some of the symptoms are bloody noses, skin rashes, pneumonia, upper respiratory infections, and what has become known as the WTC Cough – a prolonged, severe cough accompanied by shortness of breath.
Mount Sinai Medical Center, which assisted at least 20,000 responders and volunteers, runs a World Trade Center Health Program that offers free comprehensive and confidential medical examinations, ambulatory services, and inpatient treatment for World Trade Center–related physical and mental health conditions. Created in 2002 to investigate the hazards, the Mount Sinai program began screening and treating people who provided rescue, recovery, clean-up, and restoration of vital support services at Ground Zero and related sites.
In what Mount Sinai officials have described as the first long-term study of the health impacts of the World Trade Center collapse, researchers there have found "substantial and persistent mental and physical health problems" among 9/11 first responders and recovery workers, Mount Sinai Medical Center said in a statement. The data were published this month in a special 9/11 issue of the medical journal Lancet.
The Mount Sinai World Trade Center Clinical Center of Excellence and Data Center evaluated more than 27,000 police officers, construction workers, firefighters and municipal workers over the years since 9/11 and found a high incidence of several conditions, including asthma, post-traumatic stress disorder, (PTSD), depression, sinusitis, and gastroesophageal reflux disease (GERD). More than one in five of all the responders studied had multiple physical and/or mental health problems, according to the Mount Sinai study.
The study found that 43% of patients had abnormal lung function tests, indicative of lung injury. In addition, 28% of patients had asthma, 42% had sinusitis, and 39% had GERD. The data showed that 48% of rescue workers had asthma, 38% had sinusitis. As many as 43% with GERD also were diagnosed with one mental health condition, according to Mount Sinai.
Of police officers studied, 7% were diagnosed with depression, 9% PTSD, and 8% with panic disorder. About 28% of rescue and recovery workers had symptoms of depression, 32% of PTSD, and 21% of panic disorder.
First responders had the greatest exposure to the dust and smoke, and consequently sustained the most severe health problems. They were exposed to a complex mix of toxins and carcinogens that included benzene from jet fuel, asbestos, dioxin, lead, polycyclic aromatic hydrocarbons, glass fibers, hydrochloric acid, polychlorinated biphenyls. and other caustic chemicals, according to the Mount Sinai researchers. Those were among the materials released into the air with the collapse of the towers.
In another report in the Lancet the 9/11 issue, firefighters who were at the scene were found to have developed a 19% higher risk of cancer as a result to toxic fumes. The firefighters were studied by David Prezant, MD, chief medical officer of the New York City fire department and researchers from Albert Einstein College of Medicine at Yeshiva University and Montefiore Medical Center in New York.
Mount Sinai officials say their findings show the importance of long-term monitoring and treatment. "Our study shows that these diseases may persist for years to come," Philip Landrigan, MD, principal investigator for the Mount Sinai WTC program and chair of the department of preventive medicine at the Mount Sinai School of Medicine, said in a statement. has said.
In 2009, Congress passed the James Zadroga 9/11 Health and Compensation Act, which provides financial aid to sick workers. It took eight years after the attacks for patients to receive financial support. They will need that—and more—for the rest of their lives.
Caught between healthcare reform mandates and a weak economy, many physicians are observing Labor Day 2011 with little to cheer about. They are fretting that financial conditions will force them to postpone retirement indefinitely. And in this regard, they are no different from many Americans who are struggling with pressing financial concerns.
It's no surprise that Baby Boomer and older "Silent Generation" physicians plan to delay their retirement. What is surprising is that Generation Xers are also thinking about it, even though retirement is many years away, according to Jackson &Coker, an Alpharetta, GA physician placement firm
A Jackson & Coker August survey shows more than 52% of physicians who had planned to retire within the next six years have put those plans on hold, citing glum diagnoses of their economic condition.
Physicians cited declining property values, reduced retirement savings, and children's college funds as among the major reasons why they will likely continue working, as well as their loss of confidence in Social Security and Medicare. At least 70% said the loss of their personal savings and uncertainty in improving their financial condition was a main reason for delaying retirement.
"It seems like doctors are caught between recession and reform," says Sheri Sorrell, marketing manager at Jackson & Coker. "We know a lot of doctors in single practices are feeling like they have to sell their practices to a hospital because they can't afford the overhead."
Jackson & Coker did not ask the survey participants their age, only their years in practice. "It was a surprise to us that folks quite concerned about delaying their retirement are generally Generation Xers," Sorrell says. "The Baby Boomers are saying they will be doing some part-time work, or able to semi-retire up the road. For the Generation X folks, they are going to have to deal with the effects of healthcare reform."
These are the same Generation Xers who want more hospital-based employers and who don't want crazy working hours. They want a steadier paycheck, and with the economy in upheaval, they are going for Plan-B: Work as long as possible, Sorrell says.
In the survey, physicians cited economic scenarios affecting either their family or medical practices that are impacting their immediate and future plans.
"I had planned to leave the military and enter private practice," says one physician. "The group that I hoped to join was unable to follow through with their offer as two partners had to delay their own retirement due to the recession and the uncertainty created by the healthcare reform legislation. Thus, no position was available to me, so I am still in military practice with a 'wait-and-see' philosophy."
"In a group of 8, we struggled with pay in 2008," says another physician. "There were times we all took no salary. Medicare held up payments. Patients treat us like a bank. Employees have better benefits than we get ourselves. I would quit entirely if I did not have a child in college."
Added a third physician, "The recession has had a dramatic impact on my practice. I practice radiology and while volume has only decreased slightly, reimbursements have diminished and the business of radiology has allowed employers to extract additional work out of some physicians, while letting others go. Salaries have decreased up to 50%."
There certainly is a demand for more doctors. The American Association of Medical College's Center for Workforce Studies estimates a shortage of 124,000-159,000 physicians by 2025.
The association estimates that potential healthcare reforms, such as universal health coverage, will add to overall demand for doctors and increase the projected shortfall by 25%.
But although there may be more physicians who stay in practice by postponing retirement, they probably won't be enough to offset the impact of anticipated healthcare needs, says Edward McEachern, vice president of marketing for Jackson & Coker.
"We have seen a pent-up retirement demand, if you will," McEachern says. "The doctors are working longer and longer, but we're fearful of when the 401Ks do turn around and the economy turns around, you may see a huge percentage of doctors who wanted to retire and couldn't, and then decide to do so," he adds. "That will add to the severe shortage of physicians in our healthcare system."
There is some good news, however. First year medical school enrollment in 2014-15 is projected to reach 23% above 2002-2003. Current projects indicate that medical school enrollment is on track to reach a 30% targeted increase by 2018, according to the Association of American Medical Colleges.
By then, Generation Xers may feel a bit more comfortable about retirement.
Spinal fusion surgeries have increased dramaticallyin the past decade, but questions persist about the costly technique that is often used to treat older patients with lower-back pain.
Physicians are sounding alarms over unnecessary spinal surgeries and are challenging the clinical trial process for one of the most popular spinal fusion procedures. Questions are being raised about possible conflicts and the millions of dollars spent on allegedly biased studies. It's time to address these longstanding issues.'
Are there too many spinal fusion surgeries? In discussions about spine fusion techniques for an article in this month's HealthLeadersmagazine, Kamal Thapar, MD, medical director of neurosurgery and tertiary care services at Sacred Heart Hospital in Eau Clare, WI, was emphatic. "You can see the spine fusion rates and there is really no doubt fusion operations are being overdone," he said.
An April 2010 study in the Journal of the American Medical Association found a 15-fold increase in the number of spinal fusion surgeries performed for Medicare patients between 2002 and 2007. And older patients having aching backs are increasingly getting more costly and complex spinal fusion surgeries, resulting in higher rates of life-threatening complications and increasing costs to the healthcare system, according to the Oregon Health and Science University in Portland, OR.
We must determine 'where the money goes, and how it should be spent, with improved, cost-effective patient care the goal.
Are there too many conflicting interests in clinical trials for a popular spine fusion technique? The Spine Journal, the journal of the North American Spine Society, thinks so. Last month, The Spine Journal contradicted industry-sponsored clinical research on rhBMP-2, a controversial synthetic bone growth product often used in spinal fusion surgeries.
The journal scrutinized what it termed misleading and biased reports on the product, Infuse, a bioengineered material used mostly in spinal fusions, made by Medtronic, the nation's largest manufacturer of medical devices. The Journal noted that clinical studies of Infuse were conducted by surgeons who received millions of dollars from Metronic.
Medtronic estimates that Infuse is used in about one quarter of the more than 400,000 spinal fusions performed in the U.S. annually. The controversy over the clinical trials is being confronted head-on, and that is good for healthcare.
Responding to The Spine Journal reports, Medtronic earlier this month announced that it would pay Yale University $2.5 million to independently review the safety and effectiveness of its Infuse Bone Graft, which is supposed to stimulate bone growth. While critics have said the product has several side effects, including male sterility, company-sponsored researchers have blamed problems on surgeons, not on the products.
Medtronic's plan to pay Yale to evaluate its own product raises its own questions about conflict of interest.
"The financial arrangement, de facto, certainly creates a potential conflict of interest," Eugene J. Carragee, MD, editor-in-chief of The Spine Journal, and professor and vice-chairman of the Department of Orthopaedic Surgery at Stanford University School of Medicine, told HealthLeaders Media. "But the Yale group can put in certain safeguards to manage the risk of overt bias. I have no reservations about the integrity of the Yale group."
Although the Medtronic and Yale arrangement raises questions, there is widespread hope within academia and among physicians that Medtronic's decision to open for public review heretofore secretive results of clinical trials may have lasting, and positive consequences.
The review also will focus on data submitted from industry-sponsored studies submitted to the Food and Drug Administration but which was never published.
"It's a big plus – it breaks the glass ceiling, where device and drug manufacturers have said for many years that it was legally, logistically or financially impossible to even consider having a third party look at their data summaries," says Carragee. "This breaks the 'never, ever, can't do it mantra," he says. "Clearly, if Medtronic can do it with their No. 1 spine product, it can be at least on the table for discussions with companies who produce data that doesn't seem right."
Medtronic plans to give to Yale researchers all available patient data on rhBMP-2 from clinical trials it sponsored, both published as well as unpublished, and FDA adverse event reports for a comprehensive review, the Minneapolis-based company has stated. The company plans to make its clinical trial data available on ClinicalTrials.gov. It also plans to retroactively register all premarket approval and post-market studies that were completed before a requirement for registering such trials was set in 2007.
"Integrity and patient safety are Medtronic's highest priorities," Omar Ishrak, chairman and CEO of Medtronic said in a statement.
Carragee is hopeful about the broad ramifications of the Medtronic plan, but he also has concerns about the study of the spinal fusion product.
"There have been many years of repeated and categorical denials [of] associated complications by paid consultants or other surgeons with financial ties to the company," Carragee says. "Yale can get all the FDA reports in existence but because of the history of denying associated problems, they will have only the tip of the iceberg."
Harlan Krumholz, MD, a professor of cardiology and investigative medicine at Yale Medical School, will lead the independent review.
Krumholz's strategy "is to ask the right question and pick the right measurement – and it can get the right answer," Yale Medical School's Web site notes. Forbes Magazine also has called Krumholz "The Most Powerful Doctor You Never Heard Of." In the spinal surgery field, Krumholz's name will certainly become more known. Whether he pushes beyond the "tip of the iceberg" as Carragee fears, is not yet known.
Mention "Stage 1" and most physicians will think you're talking about the initial phases of a disease or a medical condition such as cancer. A few might think of a rocket launching into space.
But Stage 1 also refers to a portion of the so-called meaningful use requirements for electronic medical records, which providers must meet in order to qualify for financial incentives from the federal government.
That type of Stage 1 may be just as daunting as cancer or space flight to some older physicians who are tentative about the switch from paper files.
Patrick Golden, MD, a primary care physician and small practice owner in Fresno, CA, isn't one of them. He's unfazed when it comes to meaningful use. He has already steered his solo practice through Stage 1 approval, a journey he says has been occasionally frustrating, and sometimes funny, but ultimately worthwhile, with an EMR and a payday at the end.
"From the very beginning when I heard of the program, I knew we were going to do this. Absolutely there was no doubt," said Golden, 55. "We sought the electronic health records for a variety of reasons, even before the stimulus money was available. I thought it would be neat to upgrade our billing software. We had an old DOS (computer) system."
As of July 31, more than $397 million in Medicare and Medicaid incentive payments have been made to healthcare professionals who have demonstrated that they are making "meaningful use" of new technology.
The criteria are set over the course of the next five years. Stage 1 runs through 2011 and 2012, with financial incentives for records and data improvements such as e-prescribing.
Golden admits that when he began the meaningful use program in January 2010 it was a struggle. One nurse quit, probably over the program, and Golden and his wife spent months scanning documents, weekends, too. At the same time, he faced a Medicare audit, which he says was complicated by the switch from paper to EMR.
More than one year later, Golden has gotten some money back, and he says he runs a more efficient medical office without paper records and with an EMR portal that allows instant access to patient records, labs, and most tests. His patients are more engaged in their care, he says, and "and that's what healthcare reform is supposed to be about."
Golden says he's attracting younger patients, which he attributes to EMRs. "I have beautiful records," he says, laughing.
Golden, has been in practice 24 years as an internist, specializing in cardiology and bariatrics. An electronic dashboard system that measures his practice's meaningful use progress by collating and tracking data, has made the work much more efficient, he says. Patients are enjoying the "instant interaction and the connection they now have with us," he says. "With instant access to their records, they are taking greater ownership of their care."
"I realize this kind of stuff is going to allows healthcare to function at a lower cost in the future with respect to patient management issues," Golden says.
When Golden switched to EMR, he stopped paying the monthly rate for a storage facility for the paper records. Still, the process took months. "Most of our staff didn't help us out when it came to the scanning of the documents," Golden says. "That was mostly done with family members, and a couple of college students that we hired. It was labor-intensive for nine months. My wife and I were in the office scanning shots on Sunday."
In the meantime, CMS surprised him with an audit of Medicare patient visit codes. The paper and the electronic medical record transition appeared to confuse a CMS review, in Golden's view, leading to what he called a "funny" interaction with the agency. Still, Golden believes the electronic recordkeeping enabled him to "survive the audit."
"It was really interesting. We were audited right after we started with our electronic (records) and they requested 24 charts from one day's (work) at our office," Golden says. "Out of the 24 charts, three were paper charts. They automatically approved (the paper charts), and they automatically rejected the electronic charts, it was really funny."
"A reviewer at CMS didn't recognize the electronic signature was valid," Golden says. "Once a supervisor overruled her, they accepted everything. It was kind of comical. Eventually, we passed (the audit) with flying colors after they recognized an electronic signature made sure it was a valid one,"
"I think one of the reasons why we survived the audit without a glitch was because I had legible records."
That transition to EMR has increased payments from CMS, Golden says. "We've been getting the e-prescribing checks. Of course, I expect to get paid the $18,000 for the stimulus money, so a lot of these dollars that came back to us we would never have received had we not gone with the electronic system," Golden says.
While he is enthusiastic about EMR, Golden says there is one drawback.
"I will admit, near the end of the day, I become weary, in a different way before I had electronic records. You know, you just get tired of clicking and looking at the computer," Golden says. "I am older."
Golden's three tips for implementing EMR for any medical practice:
Get Physicians Involved. "Your doctors must be involved in the process from day one," he says. "They must be engaged and involved in learning the system and using it to be successful. They have to have a vested interest in learning the system."
Create an "In-House" EMR Expert. "If possible, try to create an in-house expert who will manage the technological aspect of the system from implementation to day-to-day operation of it. It's a long-term investment and if conducted properly from the beginning can significantly improve the health and viability of your practice, clinically and financially."
Be Patient and Flexible. "You have to be willing to change and see the positive in meaningful use. The data we're now able to track through the system – because of meaningful use – is incredible. That alone has been worth the change."
Record-breaking heat has baked parts of the nation this summer, but come winter, legislative corridors will still be sizzling. This time the heat will come from intense lobbying over how physicians are paid.
Things got underway in May when The American College of Emergency Physicians visited Congress to "enlighten" lawmakers about healthcare issues, says ACEP President Sandra M. Schneider, MD, FACEP.
The ACEP contingent called on more than half the 435 House of Representative offices and 94 of the Senate's 100 offices. They discussed everything from healthcare reform to the Sustainable Growth Rate.
The meetings were held before the contentious debt ceiling vote in July, in which Congress agreed to raise the country’s legal limit on borrowing. Earlier, this month, President Obama signed the measure, making a $2.4 trillion downpayment on the federal deficit over the next decade.
For physicians, the debt ceiling debacle may have felt like the roof caving in. "I think the debt ceiling showed how dysfunctional Washington is, on both sides of the aisle," said Schneider, an attending physician at Strong Memorial Hospital in Rochester, NY, and a professor in the department of emergency medicine at the University of Rochester.
"These issues are all hanging over (physicians') heads," Schneider added. "Physicians are going to very, very careful to see where the funding around Medicare is, and how, when, and if they are going to get paid," Schneider says. "And we're looking to fix the SGR. That's just the debt ceiling on steroids."
As a result of the debt ceiling vote, a 12-member joint commission is charged with trimming at least $1.2 trillion in federal spending over the next decade. The so-called "super committee" is required to recommend the cuts by Nov. 23, and Congress would have until Dec. 23 to vote on the plan. If the committee can't reach an agreement, a 2% cut to Medicare providers would be made automatically.
Once again, the SGR payment formula calls for deep reductions in Medicare payment rates, which has been continually delayed. Unless Congress intervenes, the SGR formula will mandate a 29.5% cut in the Medicare physician payment rate on Jan. 1. And once again, physicians say the reductions will drive doctors out of business or force them to stop seeing patients.
Nobody knows what will happen, of course, but it will be a very interesting fall and winter. Physicians are predicting one of the more vigorous lobbying efforts by their groups in sometime, with the ACEP discussions on Capitol Hill just a precursor of things to come.
The SGR is a far greater concern to physicians, says Roland A. Goertz, MD, MBA, FAAFP, president of the board of directors of the American Academy of Family Physicians. "We've analyzed this and 2% is the automatic rollback if the 12-member committee can't make a decision, or if Congress and the President can't agree," says Goertz, referring to the debt ceiling fallout. "Will 2% (reduction) make a difference? Well certainly, it will, but nowhere near the difference that the SGR would make at 29.5% if it's not dealt with."
"We are trying to make a case to have this 'fix' for five years, to put some sensibility into the system," Goertz says, referring to the SGR. He adds that it would be sensible if the super committee also addressed the SGR issue.
"I don't see anywhere that the super committee can't deal with the SGR either. Those 12 (super committee members) will be subject to the most intense lobbying effort by everybody who has a stake in this game," Goertz says. "It means everybody and anybody will be going to DC. Every organization is going to be afraid not to be there, for fear of not being heard. It's going to be a very pressure-packed period of time."
One of the problems is that the government is not being responsive in finding ways to reduce healthcare costs, Goertz says. His organization emphasizes that patient-centered medical homes and related models "have been shown to save millions of dollars," Goertz says. "I'm chagrined why the (healthcare) system isn't moving faster in that direction."
"We need to reduce "public rhetoric or public posturing," he adds."Every physician can tell you about waste that can be fixed. I hope we can get some sort of reprieve."
Physician groups will probably join together to stop funding cuts. ACEP's Schneider acknowledges each group has its own priorities, but often with overlapping problems. For instance, at least 97% of primary care physicians refer patients daily to the emergency department, according to a poll of 20,000 emergency physicians released by the ACEP in April. That's because there are too few primary care physicians, Schneider says. And then there are other matters, such as the progress of medical liability reform, which impacts physicians of many specialties, she says.
Those issues were among the reasons why Schneider and her group went to Capitol Hill to begin with, and why they will do so again, with the debt ceiling crisis added to the agenda.
William Urquhart, MD, delivered hundreds of babies in three decades as an obstetrician and gynecologist. A few years ago, he said bye-bye to the babies, and now he’s counting calories for patients. As the owner of a weight loss franchise, he’s a happy man.
No more weekends. No more nights. No more lousy reimbursements. Not as much paperwork. He misses the babies, but at age 59, the longtime Mobile, AL, physician has more time to see his own grandkids.
As the obesity epidemic balloons, physicians like Urquhart are reducing their regular practices, or leaving them altogether, to open money-making weight loss clinics. By getting involved in these weight loss clinics, physicians are seeing the revenue pile up to replace the lost revenue stream of other practices.
Urquhart opened a franchise of the Medi-Weightloss Clinic in Mobile, and has partnered with other physicians to open seven other clinics. He says he is having financial success beyond his “wildest dreams” and says he’s happily seeing changes in his patients as a result of the weight loss programs.
“My patients, I remember when they were thinner and more active, and they were chasing their little kids, and now they are huffing and puffing,” Urquhart says. “We’re trying to help them.”
A major pitch for these weight loss clinics is that they are “doctor supervised.”
There is definitely some irony here. While many weight loss clinics are marketing that physician connection, many doctors in general practice seem not to know what they are doing when it comes to dealing with patients having weight issues.
A report last year by the STOP Obesity Alliance—a collaboration of consumer, provider, government, labor, and business groups—suggested doctors and patients are frustrated with the conversations they are having about weight.
The patient survey found that only 39% of obese people are being told by a healthcare provider that they are obese. Most of those patients were also told by their doctors to lose weight. But one-third of those patients say their provider never discussed ways to achieve or maintain a healthier weight.
The survey itself revealed conflicts, says Christine Ferguson, JD, director of STOP Obesity Alliance, in Washington, DC. “A huge percentage [of physicians] had never had any [specific weight loss] training. “
“Yet at the same time, they know what people need to do, for the most part: help people eat less and exercise more, with patients needing to change their eating habits,” says Ferguson, a professor of the School of Public Health and Health Services at The George Washington University. “Then, you look at the patient, and they say not only do they not know what the physicians are telling them, but they don't pay attention to what the physicians are telling them.”
A major problem, as indicated in the survey, is that a vast majority of doctors say they have little or no training in weight management and nutrition, Ferguson says. Moreover, they say they’re not likely to have anyone else in their practice who can be of help, she adds. Most primary care physicians say having more time with patients would help them discuss weight issues, but many also cite a need for weight loss tools and other programs, the survey found.
Ferguson says the “real dichotomy is how people view weight as an issue. A lot of people still don’t believe it belongs in a physician’s office.”
Then, there’s the issue of a physician who may have a “difficult time talking to a patient. It could be the way the office visit was structured: If you have six to 10 minutes, and you have four issues to address, it's kind of hard to go into the weight issue.”
But doctors who leave or cut back on practices are finding success by specifically focusing on weight management issues, Urquhart says.
Medi-Weightloss Clinics, basedin Tampa, FL, has 92 weight loss franchises in 22 states. Physicians who buy a franchise either share a roof with their existing practice, or locate it nearby and refer their patients to the cash-based business. Under a physician's care, patients are given a full health consultation and weekly lessons on eating, exercise, and lifestyle change.
Urquhart says he loves seeing the changes in his patients, many of whom he has known for a long time and who have struggled with weight. “If you get someone to lose weight, lower their blood pressure, help prevent diabetes, help with sleep apnea, and just help them feel better and be more active, then you are doing something good,” Urquhart says. “You have to be very passionate about it. You treat your patients well, and you have a nice business model.”
“I’m making a great living, I’m helping my patients lose weight,” he says, and no longer has to “deliver babies anymore at all hours of the night and weekends.”
Doctors across the country are looking for ways to supplement their income,” he adds. “There are all kinds of sideline business that doctors are trying, whether it's in Botox and spas, or weight loss centers,” Urquhart says.
Ferguson, of the STOP Obesity Alliance, says she can see the pluses for a physician like Urquhart going into the weight loss clinic world. “It may be saying, ‘this is such a relief to me, knowing [patients] are coming in specifically about weight; I'm able to devote this time to this person, and talk to this person, because I'm not worried about insurance, how much time I have, and this person is cash and carry,” she says.
Within the physician-run weight loss clinic, “you've got a motivated provider, a motivated patient, in a direct pay relationship,” Ferguson says. “This will be a better interaction than someone coming into the doctor's office in a pre-diabetic condition and complaining about being tired, and not wanting to talk about weight loss, and the doctor trying to figure out in 10 minutes.”
The STOP Obesity Alliance has no figures on how many physicians are opting to leave or reduce their practices for the weight loss clinic field, Ferguson says, although Medi-Weightloss Clinics issued a statement saying more doctors are going into the field.
As an OB/GYN, Urquhart says he noticed he and his colleagues “just didn't have the time to deal with it and we were not structured to deal with it,” referring to weight loss issues. Now, he's dealing with weight loss, all the time. Bye-bye, babies.
